What are the choices of antiepileptic (antiepileptic drugs) medications for different types of pediatric epilepsy?

Choice of Antiepileptic Drugs in Different Types of Pediatric Epilepsy

For pediatric convulsive epilepsy, start with monotherapy using carbamazepine for partial onset seizures or valproic acid for generalized seizures, with phenobarbital as a cost-effective alternative when availability can be assured. 1

Acute Seizure Management

Status Epilepticus and Prolonged Seizures

• Without IV access: Administer rectal diazepam as first-line treatment; IM phenobarbital is an alternative when rectal diazepam is not feasible 1
• With IV access: Use IV lorazepam (preferred) or IV diazepam; for sustained control, follow with IV phenobarbital or phenytoin 1
• Refractory status epilepticus: After benzodiazepine failure, use IV phenytoin, fosphenytoin, or valproate as second-line agents 1

Febrile Seizures

• Simple febrile seizures: Follow standard fever management protocols and observe for 24 hours; do NOT use prophylactic antiepileptic drugs 1
• Complex febrile seizures: Admit for inpatient observation with appropriate investigations (blood tests, lumbar puncture); prophylactic intermittent diazepam during febrile illness may be considered for recurrent or prolonged cases 1

Chronic Epilepsy Management by Seizure Type

Partial Onset Seizures (Focal Epilepsy)

• First-line: Carbamazepine is preferentially recommended for children with partial onset seizures 1
• Alternative options: Phenytoin, phenobarbital, or valproic acid can be effective 1, 2
• Newer agents: Levetiracetam (approved for ages 4-16 years at 60 mg/kg/day target dose) has favorable side effects with comparable efficacy 3, 4, 5
• Avoid: Do not routinely prescribe antiepileptic drugs after a first unprovoked seizure 1

Infantile Spasms

• Drug of choice: Vigabatrin remains the preferred treatment for infantile spasms 1
• Alternative: ACTH or corticosteroids are effective options 4, 6
• Duration: Limited data suggest withdrawal after 6 months of spasm-free period without relapse 1
• Special indication: Vigabatrin is particularly effective in children with seizures caused by tuberous sclerosis 1
• Critical monitoring: Visual field examination required every 6 months in children with cognitive age >9 years due to risk of visual field defects 1

Absence Seizures

• First-line options: Ethosuximide and valproic acid are superior to lamotrigine for absence seizures 4, 2
• Valproic acid advantage: Use when both absence and tonic-clonic seizures are present, as it covers both seizure types 2
• Avoid: Do not use carbamazepine or phenytoin as monotherapy, as they do not control absence seizures 2

Generalized Tonic-Clonic Seizures

• Most effective: Valproic acid remains the most effective drug for broad-spectrum coverage of generalized epilepsies 4, 2
• Alternatives: Carbamazepine, phenobarbital, phenytoin, or primidone are effective for tonic-clonic seizures alone 1, 2
• Combination therapy: If valproate cannot be used and myoclonic or absence seizures coexist, add ethosuximide or a benzodiazepine to the primary agent 2

Juvenile Myoclonic Epilepsy (JME)

• Drug of choice: Valproic acid is the preferred agent for JME with myoclonic seizures 2
• Levetiracetam option: Approved as adjunctive therapy for patients ≥12 years with JME at 3000 mg/day target dose 3
• Avoid: Vigabatrin exacerbates myoclonic seizures and should NOT be prescribed in idiopathic generalized epilepsies 1

Secondary Generalized Epilepsies (Tonic, Atonic Seizures)

• Challenging treatment: These seizure types are difficult to treat with any single drug 2
• Consider: Valproic acid or combination therapy, though no single agent is clearly superior 2

Special Populations and Considerations

Children with Intellectual Disability

• Preferred agents: Use valproic acid or carbamazepine instead of phenytoin or phenobarbital due to lower risk of behavioral adverse effects 1
• Individualized approach: Drug choice depends on seizure type, but prioritize agents with better cognitive/behavioral profiles 1, 4

Cognitive and Behavioral Considerations

• Best tolerated: Lamotrigine and rufinamide are optimal for children with cognitive and/or attention problems 5
• Levetiracetam: Generally favorable cognitive profile, making it suitable for children with neurodevelopmental concerns 5
• Avoid high doses: Topiramate and other agents with known cognitive effects should be used cautiously and at lower doses 5

Girls and Women of Childbearing Potential

• Avoid valproic acid: Should be avoided if possible due to teratogenic risks 1
• Monotherapy preferred: Use minimum effective dose of a single agent 1
• Folic acid: Routinely prescribe when on any antiepileptic drug 1

Treatment Duration and Discontinuation

When to Stop Antiepileptic Drugs

• Timing: Consider discontinuation after 2 seizure-free years 1
• Weaning protocol: Slow taper over 6 weeks or longer 4
• Success rate: Approximately 70% of patients remain seizure-free after discontinuation; most who relapse regain control with restarting medication 4
• Decision factors: Consider clinical, social, and personal factors with patient and family involvement 1

Drug-Resistant Epilepsy

When Medical Therapy Fails

• Definition: Failure of two or more appropriately chosen and tolerated antiepileptic drugs 4
• Next steps: Consider epilepsy surgery, vagal nerve stimulation, or dietary therapies (ketogenic diet) 4
• Polytherapy: Combination of two major antiepileptic drugs may be necessary, but avoid more than two agents when possible 2

Critical Pitfalls to Avoid

• Do not use vigabatrin for absence or myoclonic seizures—it will exacerbate them 1
• Do not use carbamazepine or phenytoin alone for generalized epilepsies with absence or myoclonic components 2
• Do not routinely use EEG or neuroimaging for diagnosis and treatment initiation in non-specialized settings 1
• Do not prescribe antiepileptic drugs after a first unprovoked seizure in most cases 1
• Monitor visual fields every 6 months in children on vigabatrin who can cooperate with testing 1